Authorization & Consent

Authorization & Consent

To Send Unencrypted Patient Information by Email and Other Electronic Means

Until I tell you in writing to stop, I authorize Hudec Dental to transmit personal information relating to my treatment, health or general advice given to me by email or other electronic means, without encryption or special security precautions, to me or someone I designate, or to other health care providers, health plans and others involved in my treatment or Hudec Dental’s health care operations. The personal information that may be emailed may include my pictures, x-rays, health history, diagnosis and treatment.

I understand that:

•         I do not have to acknowledge this form.

•         My treatment, enrollment and eligibility for benefits will not be affected by my decision about acknowledging this form.

•         If I don’t acknowledge this form, Hudec may use other ways to send my information, such as U.S. Mail, or may ask me to send my information to third parties myself.

•         There is some risk that emails and other electronic messages may be improperly acquired by hackers or received by unintended recipients. If that happens, the information may be re-disclosed and no longer protected by privacy law.

•         Hudec Dental does not email such sensitive personal information as Social Security number, credit card number, mental health diagnosis, genetic information, alcohol/substance abuse, or positive HIV status unless the patient insists.

•         I can tell you in writing to stop emailing my patient information at any time, but if I do so, this will not affect emails that Hudec Dental already sent before receiving my written instructions to stop.

By acknowledging this, I have read, understand, and authorize consent to the above information. I have the right to receive a copy of this acknowledgement upon request.